Breast Surgery Guidelines Take Aim at Unnecessary Operations

New guidelines recommend against surgery to remove additional normal tissue in women who’ve already had a lumpectomy.

Summary

The new guidelines take aim at resolving questions over whether surgery to remove additional normal tissue is needed in breast cancer patients who’ve already had a lumpectomy.

Between 70 and 90 percent of women with newly diagnosed, early-stage breast cancer are candidates for breast-conserving surgery, or lumpectomy, followed by radiation. In this procedure, surgeons remove the cancer along with a small amount of normal tissue surrounding the tumor — known as a surgical margin — to reduce the chance of leaving cancer cells behind.

Roughly 25 percent of women who receive a lumpectomy return to the operating room to have additional normal tissue removed. Of these women, approximately half have negative margins — defined as no tumor cells at the edge of the lumpectomy specimen. It has been widely thought that increasing the surgical margin would lower the risk of the cancer returning in that breast.

Now a new guideline issued jointly by two medical organizations recommends against performing this second procedure following lumpectomy. The guideline is expected to save patients from unnecessary surgery while still minimizing the risk of the cancer returning.

“It was important for us to create this guideline because we want women to have the confidence to select a lumpectomy rather than a mastectomy when medically possible and breast cancer physicians to be confident about knowing when a margin is adequate,” says Monica Morrow, Chief of Breast Cancer Surgery at Memorial Sloan Kettering, who cochaired the new guideline development.

Dr. Morrow notes that some women with early-stage breast cancer choose to have a mastectomy (removal of the entire breast) rather than a lumpectomy due to fears of cancer recurrence.

Determining Risk of Recurrence

After conducting a review of the available scientific evidence, a panel of breast cancer experts from the Society of Surgical Oncology (SSO), the American Society for Radiation Oncology (ASTRO), the American Society of Clinical Oncology (ASCO) , the American Society of Breast Surgery (ASBS), and the College of American Pathologists (CAP), as well as patient advocates, found that removing additional tissue did not significantly decrease the risk of recurrence in the same breast in women who received radiation treatments to the entire breast, which is standard practice.

This was found to be true regardless of a woman’s age and whether she had one of the more aggressive, triple-negative cancer types.

Based on its findings, the multidisciplinary panel, which reviewed 33 studies involving 28,162 patients, developed comprehensive, evidence-based guidelines for lumpectomy margins in an effort to spare many women from unnecessary surgery.

“The definition of the appropriate surgical margin for breast cancer has been a major controversy for decades, but we see excellent outcomes in women who undergo lumpectomy followed by radiation therapy,” says Dr. Morrow.

In general, the ten-year survival rate is considered the same for both mastectomy and lumpectomy plus radiation therapy, but lumpectomy offers a faster recovery time and improved cosmetic outcomes while lowering total healthcare costs.

The new guideline is endorsed by the SSO, ASTRO, ASCO, and the ASBS. It can be downloaded on the SSO’s website, at www.surgonc.org/margins-study. Additional resources can be found in the SSO’s Annals of Surgical Oncology.

The guideline was produced with a grant from the Susan G. Komen Foundation.

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Comments

Myra Taylor

Feb 27, 2014 • 5:22 PM

I don't understand. It seems as though 12.5 percent of women who have a lumpectomy have cancer cells at the edge of the lumpectomy specimen. Is this suggesting that it's OK for these women to walk around with cancer cells just to avoid unnecessary surgery? if I were in that 12.5 percent, I'd want those cells removed to reduce the risk of recurrence.

Dear Myra, we sent your inquiry to Dr. Morrow, who further clarified what the guideline says. She responded, "If cancer cells are at the edge or margin, then more surgery is needed. If cancer cells are only close to the edge, then removing more NORMAL breast tissue is not needed."

Thanks for your comment.

Anita Bhaduri

Feb 28, 2014 • 1:05 AM

How about frozen section for margin status? Is it still being done for lumpectomies and revised margins?

Dear Anita, at Memorial Sloan Kettering, the assessment of margin status does not routinely involve evaluation by intraoperative frozen section because it can cause tissue artifacts that can limit accurate pathologic evaluation. Thank you for your comment.

Debra

Feb 28, 2014 • 10:51 AM

Why is triple negative small cancer, stage 1 under 2 cm treated so aggressively if
Node status is negative.
How often are nodes found to have cancer cells in such early small cancers

Debra, we forwarded your questions to breast cancer experts Monica Morrow and Clifford Hudis. They explained that triple negative breast cancers are associated with higher risks of recurrence as compared to similarly sized tumors that have estrogen, progesterone, or HER2 expression, even when the nodes are negative. In addition, the only proven therapies for this subtype of breast cancer are surgery, radiation, and chemotherapy. Hence they are treated with these modalities when otherwise appropriate. They also said that the surgical treatment of triple negative cancer does not differ from the treatment of estrogen receptor-positive or HER2-positive cancers. Thank you for your comment.

Debra

Feb 28, 2014 • 3:41 PM

Thanks. Complete mastectomy would reduce or eliminate the chance of
Local recurrace since no breast tissue is left??

Debra

Feb 28, 2014 • 3:44 PM

It might be naive question. If small 1.5 cm triple negative cancer node negative and total mastectomy done. What are the chances of reurrance over years?
Any statistics or numbers? I am aware of multiple factors in addition.

Debra, unfortunately we are not able to answer these kinds of specific medical questions on our blog. If you'd like to make an appointment to speak with a Memorial Sloan Kettering doctor, you can call our Physician Referral Service at 800-525-2225 during regular business hours or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

Pamela

Mar 6, 2014 • 12:20 AM

How can 10 yr survival rate for stage 1 node-negative BC be same for mastectomy and lumpectomy/radiation? If there's a greater chance of local recurrence w lumpectomy them wouldn't the chance of a new invasive BC arising which may verb be node positive impact the 10-yr survival rate? Also why are 10 yr survival rates always quoted instead of 20?

Pamela, we sent your questions to Dr. Morrow, who responded, "The chance of local recurrence is the same after mastectomy and lumpectomy and radiation therapy. Many years ago when lumpectomy first started the risk of local recurrence was higher with that procedure, but that is no longer true. The majority of recurrences and deaths occur within ten years so that is why ten-year survival statistics are used. At 20 years there is a high rate of death from nonbreast cancer causes, which makes the statistics difficult to interpret." Thank you for your comment.

Ann Denning

Mar 7, 2014 • 1:45 PM

What would determine the choice ,after a lumpectomy and then radiation therapy which doesn't kill the cancer cells. why have radiation therapy if it doesn't eliminate the cancer . Why not have the mastectomy after the lumpectomy therapy? Who makes that determination and how does it come about.

Ann Denning

Mar 7, 2014 • 1:46 PM

All these decisions are very confusing one has to make and a clearer understanding would be helpful to lay people.

Ann, thank you for your comment. We consulted with Dr. Morrow who replied:

The choice to have a lumpectomy or mastectomy is made before any surgery is done. All visible cancer cells are removed with the lumpectomy. The radiation helps to reduce the risk of cancer coming back in the future. Today, the risk of cancer recurring in the breast after lumpectomy and radiationis quite low and more than 90% of women never have this problem. If cancer comes back in the breast after lumpectomy and radiation then a mastectomy is done. On rare occasions when lumpectomy is attempted and all the cancer cannot be removed, meaning the margins are not free of cancer cells, then a mastectomy is done.

Paula, thank you for your comment. For guidance on the minimal acceptable margin, we suggest you consult the link that appears at the very end of the article.

Regina Barros-Rivera

Mar 15, 2014 • 12:24 PM

I am confused. My margins came back positive for atypical cells, is that the same as cancer cells? . I am told it is not not cancer but abnormal cells and we do not know if they will turn to cancer therefore we will try again to get clean margins. Why wouldn't the radiation treatment and hormonal treatment be enough to prevent recurrence?

Regina, unfortunately we are not able to provide personal medical advice on our blog. We recommend you speak to your doctor about this. If you'd like to make an appointment to speak with a doctor at MSK you can call 800-525-2225 during business hours or go to http://www.mskcc.org/cancer-care/appointment for more information. You might also want to reach out to the National Cancer Institute's Cancer Information Service at 800-4CANCER for more general information. Thank you for your comment.

Dr. Agarwal, thank you for your comment. Unfortunately, specific medical questions cannot be answered on this blog, but we recommend you consult the guidelines mentioned at the end of the above story. (A link is provided.)

SANDS

Apr 6, 2014 • 12:22 PM

I HAVE HAD BILATERAL LUMPECTOMIES - 10 YEARS APART. TODAY, IO YEARS FURTHER ALONG THE ROAD A MICRO RECURANCE HAS BEEN FOUND.
I AM TORN ABOUT WHETHER TO HAVE A LUMPECTOMY AGAIN (3RD) OR A BILATERAL MASTECTOMY AND RECONSTRUCTION.
DOES A RECURANCE SIGNIFY A GREATER LIKLIEHOOD OF METASTISIS?

Dear Sands, we are sorry to hear that you have experienced a recurrence. Unfortunately, we can't answer personal medical questions on the blog. If you would like to consult with one of our specialists, please make an appointment through our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

Sheri

Jun 28, 2014 • 9:26 AM

I have recently been diagnosed with invasive ductal carcinoma. I have met with one surgeon at a small local hospital who told me my cancer is in early stage. I would like to obtain a 2nd and possible third opinion and am currently researching hospitals and surgeons. Are there surgical and technology advancements that improve the chances of total resection (lower the chance of needing a 2nd surgery)?

Sheri, we are sorry to hear about your diagnosis. We are not able to answer individual medical questions on our blog. If you'd like to come to MSK for a second opinion or for treatment you can call 800-525-2225 during regular business hours or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

LES

Aug 25, 2014 • 6:57 AM

For a 3cm, triple negative ductal BC, what factors determine if it is chemo first and then surgery (Lumpectomy or complete) on any remaining tumor cells or
surgery first and them chemo. What are the lifetime limit guidance on radiation tolerance? (for example if one has received 25 years ago 5K after thymectomy, can additional radiation therapy be safe?

Please keep in mind, we cannot respond to personal medical questions because recommended treatment will depend on the particular details of each patient's medical history and diagnosis. However, you can find some general information about when chemotherapy is used before versus after surgery here: http://www.mskcc.org/cancer-care/adult/breast/systemic-therapy.

For your question about radiation, we did reach out to Simon Powell, who heads our department of radiation oncology. He writes: "Each re-irradiation case is different and generalizations are not possible. This is why patients need to see a radiation oncologist, preferably at a center like MSK, where we have a large experience in re-irradiation. Re-irradiation can be given in numerous situations, which is why an opinion should be sought."

Thanks again for your comment.

Kate

Jul 27, 2016 • 9:41 PM

I have recently had a lumpectomy and was to have radiation. After lumpectomy found out I was HER2 positive and estrogen and progesterone positive and that I would also need chemotherapy for 12-16 weeks including herceptin which would continue for a year. I would then have radiation. At that point I decided to look more closely at the family history and speak with some relatives. I knew that my Aunt (mother's side) had ovarian cancer in her 40s. My grandmother on my maternal side also had cancer (at the time of her death they just called it woman problems and bleeding) and my older first cousins believe it was ovarian or uterine. The daughter of my Aunt that had ovarian cancer had a mastectomy at a very early age (38) and I have another first cousin that was diagnosed with breast cancer in her 40s (I have not been able to reach her to find out what kind of surgery or treatment she had. I am very concerned and have been doing some more research and my question is --- Would you advise someone with my history to opt for a preventive mastectomy due to family history?

Dear Kate, we are sorry to hear about your diagnosis and your family's history with cancer. The decision to have prophylactic surgery is a complex one that takes into account a number of different factors. Speaking with a genetic counselor to discuss the possibility of genetic testing may be helpful as you consider your options. The information gained could help you and your doctor make decisions about your care, including screening and risk-reducing medication and/or surgery. If you are interested in scheduling an appointment with someone in our Clinical Genetics Service, please call 646-888-4050. To learn more, please visit https://www.mskcc.org/cancer-care/risk-assessment-screening/hereditary-…. Thank you for reaching out to us.

Carleen Cerowley

Sep 16, 2016 • 10:51 PM

How can invasive intraductal cancer be called early stage? And be told lumpectomy +rad. Is appropriate?

Dear Carleen, to learn more about how breast cancers are staged, please visit https://www.mskcc.org/cancer-care/types/breast/diagnosis/stages-breast. Every woman's disease is different, and treatment recommendations are based on a number of factors. We recommend that you circle back with your oncologist to discuss any concerns you may have regarding your care. If you are interested in making an appointment for a second opinion with and to discuss your treatment options, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

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We welcome your questions and comments. While we share many of them with our world-class doctors and researchers, we regret that in order to protect your privacy, we are not able to make personal medical recommendations on this forum, nor do we publish comments that contain your personal information. If you would like to consult with an MSK doctor, we encourage you to make an appointment at 800-525-2225 or request an appointment online.